Fillable Dental Hygiene Application Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Dental Hygiene Application Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Dental Hygiene Application Checklist
There are 3 ways to obtain a license as a dental hygienist in the State of New Jersey.
1. Licensure by N.E.R.B.
2. N.E.R.B. past ve years
(If you took the N.E.R.B. more than ve years ago, and are licensed in another state, you may apply by “N.E.R.B. past ve years.“
3. Licensure by credentials
(If you have a current license in another state, obtained by some other state or regional clinical examination, you may apply by
“Licensure by credentials.” Score reports of this examination must be submitted with application.)
Use this check-list to determine that you have complied with all of the requirements. Once your application is received, a le will be
established and you will be notied if any documents are missing. The Jurisprudence Exam can be taken at any time during this process.
Please refer to the Jurisprudence Examination information enclosed with this packet.
______ Complete and return the Certication and Authorization Form For a Criminal History Background Check (now required by
law). Instructions will be provided in a follow-up letter once your application has been received and processed.
______ Application Fee (nonrefundable):
1. If you have taken the A.D.E.X. clinical examination please enclose a check or money order for $75.00
2. If you are applying through reciprocity (a licensee who has taken another state or regional clinical examination currently
licensed in another state or jurisdiction) please enclose a check or money order for $125.
Checks should be made payable to "State of New Jersey" and sent with this application to:
NJ Board of Dentistry, P.O. Box 45005, 124 Halsey Street, 6th Floor, Newark, NJ 07101
______ Answer all questions on the application form.
______ Staple one passport size photograph to the front page of the application. Please sign and print your name along with the date
on the back of the photo.
______ Enter your social security number.
______ Have your dental hygiene school(s) provide an ofcial school transcript in a sealed envelope. DO NOT open the envelope.
Attach each sealed transcript(s) with the application, or arrange to have the school(s) forward the transcript(s) directly to the
Board ofce.
______ Make photocopies of the State Verication Form (SV1.DH) and mail to each state in which you hold (or held) a license. Each
state must ll out the form, stamp it with their ofcial state seal and mail it directly to NJ Board of Dentistry, P.O. Box 45005,
124 Halsey Street, 6th Floor, Newark, NJ 07101.
_______ List the date that each exam was taken in the Examination History section.
_______ Please provide your DENTPIN (Dental Personal Identication Number) number so the Board may obtain your scores from the
National Board Exam. ALSO, CONTACT THE NATIONAL BOARD TO ELECTRONICALLY RELEASE YOUR SCORES
TO THE NJ STATE BOARD.
_______ Please use additional paper if you cannot t all of your information in the space provided on this form. Make a notation by
each question that more information has been attaclied. Please mark your attached answers with the same number corresponding
to the question that you are answering.
_______ If you have answered “Yes,” to any of the child support questions, please attach an explanation on a separate piece of
paper to this application form.
_______ Fill out the Medical Conditions form from your packet and send back with your application.
_______ Once the entire application has been completed, have it signed and sealed by a Notary Public.
Upon approval of your application you will be notied by letter and requested to provide your initial biennial license fee.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Application for a Dental Hygiene License
Date: _______________________________
A nonrefundable application ling fee of $75 (or $125 if you are applying by reciprocity) in the form of a check or money order made
out to the State of New Jersey, must be submitted with this application. (Applicants should understand that if the fees are paid with a
personal check, and the check is returned by the bank due to insufcient funds, the next step in the licensure process will be delayed
until the fees are paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are
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equired
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a
ddress
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esponse
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esidence
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ecord,
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esidence,
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the public. One of your addresses must include a street, city, state and ZIP
code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: _______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: _____________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
In this box staple a clear, full-face
passport-style photograph (2˝x 2˝)
of your head and shoulders, taken
within the past six months.
A photo is required with each
application.
- 1 -
For ofce use only
Application number:
______________________
Check or money order:
______________________
Date processed:
______________________
License number:
______________________
3. Social Security
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: ______ - ______- _______
*Pursuant to N.J.S.A. 54:50-24 et. seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board is required to
obtain your Social Security number. Pursuant to these authorities, the Board is also obligated to provide your Social Security
number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records,
b. the Probation Division or any other agency responsible for child support enforcement, upon request, and
c. the National Practitioner Data Bank and the HIP Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
Education
5. List, in chronological order, institutions where you attended dental hygiene school. Do not include predental hygiene courses.
Attach a sealed ofcial school transcript from each school(s) listed below.
Months and Years Hygiene School City, State, County
_____ / _____ to _____ / _____ ____________________________________ ________________________________
_____ / _____ to _____ / _____ ____________________________________ ________________________________
_____ / _____ to _____ / _____ ____________________________________ ________________________________
I received my dental hygiene degree on ____________________________________.
Month Day Year
6. Other State Board Licenses
For each state listed, Form SV1.DH (enclosed with this packet) must be completed by each licensing jurisdiction and sent to the
Board ofce. (Please list all of the states in which you have or have had a license, including inactive or retired status. Attach
a separate sheet of paper if necessary.)
State ___________________ Status ___________________ State ____________________ Status ____________________
State ___________________ Status ___________________ State ____________________ Status ____________________
State ___________________ Status ___________________ State ____________________ Status ____________________
- 2 -
7. Have you ever taken a state board or regional board examination and failed? Yes No
8. Please provide your National Board DENTPIN number: _______________________________________________
9. List the name and address of every dentist by whom you have been employed in the practice of dental hygiene (include any period
in the Armed Services and other positions held in the elds of health, education etc.). For each listing, be sure to indicate the dates
you were employed.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
10. Have you previously applied for a license as a dental hygienist in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
If “Yes,” when and where? _________________________________________________
11. Do you currently hold, or have you ever held a professional license of any kind in New Jersey, any other state, the District of
Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license held, provide the date(s) held and the number(s). If the license was issued under a different name, please
provide that name. __________________________________________________________________________________
Last name First name Middle initial
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
12. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in this or any other state
or in a foreign country? (Parking or speeding violations need not be disclosed, but motor vehicle violations such as driving while
impaired or intoxicated must be.) Yes No
13. Have you ever been convicted of any crime or offense under any circumstances such as, but not limited to, a plea of guilty, non vult,
nolo contendere, no contest, etc., or a nding of guilt by a judge or jury? Yes No
14. Have you ever been disciplined or denied a dental hygiene license or any other professional license in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
15. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
16. Do you hold a current D.E.A. registration? Yes No
If “Yes,” has this registration ever been suspended or revoked? Yes No
17. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any
agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
- 3 -
18. Have you ever been named as a defendant in any litigation related to the practice of dental hygiene or other professional practice in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
19. Are you aware of any investigation pending against a professional license issued to you by a professional board in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
20. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
21. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of dental hygiene or other professional practice in New Jersey, any other state, the District of Columbia or in
any other jurisdiction?
Yes No
If the answer to any of the above questions, numbers 12 through 21, is “Yes,” provide a complete explanation of the
circumstances leading to the action, and any supporting documentation, on separate sheets of paper.
22. Student Loan
Are you in default in regard to any student loan obligation(s)?
Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license or certicate unless you provide the
required documents concerning the plan for repayment of your student loan.
23. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation?
Yes No
(1) If “Yes,” are you in arrears in payment of said obligation?
Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months?
Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ _______________________
Applicant’s name (please print) Applicant’s signature Date
- 4 -
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signature
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Medical Conditions Questions
Questions 24 through 29 pertain to medical conditions and use of chemical substances. Please read the denitions carefully. Your
responses will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer those
portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity if you have
reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you may assert
the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in good faith. If
you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on the application.
Your application for licensure will be processed if you claim the Fifth Amendment privilege against self-incrimination. You should
be aware, however, that you may later be directed by the Attorney General to answer a question that you have refused to answer on
the basis of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded by statutory law. (N.J.S.A.
45:1-20.)
“Ability to practice as a dental hygienist” is to be construed to include all of the following:
a. The cognitive capacity to exercise reasonable dental hygiene judgments and to learn and keep abreast of professional developments;
b. The ability to communicate those judgments and related information to patients and other interested parties, with or without
the use of aids or devices, such as voice ampliers; and
c. The physical capability to perform the duties of a dental hygienist, with or without the use of aids or devices, such as corrective lenses
or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
diabetes, mental retardation, emotional or mental illness, specic learning disabilities, H.I.V. disease, tuberculosis, drug addiction,
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
prescription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
two years.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
24. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety? Yes No
25. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
26. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the eld of practice,
the setting or manner in which you have chosen to practice? Yes No Not applicable
27. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety? Yes No Not applicable
28. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
29. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is dened as “within
the last two years.”) Yes No
If you answered “Yes” to question 29, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to determine
whether an unrestricted license or certicate should be issued, whether conditions should be imposed or whether you are not
eligible for licensure or certication.
____________________________________________________ ___________________________________
Signature of applicant Date
- 5 -
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signature
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AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: __________________________________________________
County of: ________________________________________________
I, ________________________________________________ , in making this application to the New Jersey State Board of Dentistry for
licensure under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the New Jersey State Board of Dentistry,
swear (or afrm) that I am the applicant and that all information provided in connection with this application is true to the best of my
knowledge and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufcient to deny
licensure or to withhold renewal of or suspend or revoke a license issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:6-1 et seq., together with the Rules and Regulations of the New Jersey State Board
of Dentistry, N.J.A.C. 13:30-1.1 et seq., and fully understand that in receiving licensure from the Board, I bind myself to be governed
by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualifications for licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records requested by
the Board.
__________________________________________________
Signature of applicant
Sworn and subscribed to before me this __________________
day of ____________________________ , ______________
Month Year
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
For ofce use only
Date received _______________________________ N.E.R.B. Certication date ________________________
Application number __________________________
License number _____________________________ N.E.R.B. scores
Certication date ____________________________ Comp. ______________________________
National Board certication date ________________ Clinical _____________________________
} ss.
- 6 -
Afx Seal Here
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signature
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signature
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- 7 -
Form SV1/DH/08
Board seal
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Verication of State License
Dental Hygiene
A separate form must be used for each state.
(This form may be reproduced.)
Name of applicant: _______________________________________________________________________________________
Last name First name Middle initial
The above-named applicant is a licensee of the State of ____________________________________________ and was issued
license number __________________________ on ________________________________ .
Month Day Year
The applicant was licensed by:
State or Regional Clinical Examination (Please list below.)
N.E.R.B. __________________________
Date passed
National Hygiene Board Examination ________________________
Date passed
Endorsement/Reciprocity from the State of ____________________________
Other (Please list below.)
The license status is:
Current and in good status expiring on ______________________ Revoked or suspended
Date
Inactive/expired on ________________________ Other (Please attach explanation.)
Date
Examination History (if applicable)
Date of examination Subject Grade
____________________________________ ______________________________________________ _______________
____________________________________ ______________________________________________ _______________
The licensee does / does not have a record of disciplinary history with this agency. (Attach additional information if applicable.)
Certication
I hereby certify that to the best of my knowledge and belief, the foregoing is a true statement of the record of the individual on this form.
________________________________________________
Name of Board
________________________________________________
Name of person completing this form
________________________________________________
Title
________________________________________________
Signature
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signature
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
CertifiCAtion And AuthorizAtion form
f
or A CriminAl history BACkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
Last First Middle Maiden Name
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
Month Day Year
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history background process.
Please send no payment now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certication by any other any other Board or Committee of the New Jersey Division of Consumer Affairs (a background
check conducted for the Department of Education, another state agency or another state does not apply) you will not be re-
quired to be ngerprinted a second time. However, the Division must perform a criminal history background check each time
you apply for licensure or certication. The fee for this service is $18.75. Payment should be made in the form of a check or
money order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.)
Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Mr.
Mrs.
Ms.
Ofcial Use Only
Dual License
License Type 1
_____________________
Applicant’s Number
_____________________
License Type 2
_____________________
Applicant’s Number
_____________________
Ofcial Use Only
Resubmit
______________________
Board or Committee
______________________
- 8 -
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufcient to deny certication or licensure or to withhold renewal of or suspend or revoke a certicate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________ _________________________________
Signature of applicant Date
Rev. 1/2/19
- 9 -
- 10 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Jurisprudence Examination/Orientation
As of April 2017, the Board has determined that all applicants for licensure must complete
an online orientation that focuses candidates on a number of statutes and regulations that are
specic to the practice of dentistry, dental hygiene and dental assisting in the State of New Jersey.
This orientation is free and available 24/7 through the Internet. Links to each of the orientations are
on the application section of the Board’s website at: www.njconsumeraffairs.gov/den.
It is also suggested that you review the “Application Process Overview” that is listed above the
application packet under your license category. This slide show will give you useful information
about how to navigate the licensing process.
NOTE: It is requested that you submit your application to the Board office prior to completing
the orientation. This will assist the Board with compiling your materials in a timely manner
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Dental Hygiene Application Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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